Heartburn and GERD

Many people have heartburn every now and again after eating a large meal, and will be familiar with the unpleasant burning feeling in their chest, just behind their breastbone.

Many people have heartburn every now and again after eating a large meal, and will be familiar with the unpleasant burning feeling in their chest, just behind their breastbone. It is normal to belch (“burp”) after a meal too. Sometimes partially digested food comes back up into your throat or mouth from your stomach. This is known as regurgitation, and is associated with a sour taste in your mouth.

Up to 20 out of 100 people living in Western countries regularly have problems like heartburn or regurgitation. Although both of these can be unpleasant, they do not usually lead to other health problems. But if you have very frequent or severe heartburn, often have regurgitation, and feel that it is having a big effect on your everyday life, you may have what is known as “gastro-esophageal reflux disease”, or GERD for short. “Gastro-esophageal” means “stomach and food pipe”.
If someone has reflux, some of the contents of their stomach leak out and flow back into their food pipe (also known as “gullet” or “esophagus”), because the entrance to the stomach does not close properly.

The passage between the food pipe and stomach is normally closed. It opens when the mixture of chewed food and saliva reaches the lower end of the food pipe. Once the food has entered the stomach, the lower end of the food pipe closes again.

This ensures that the contents of the stomach do not flow back.

If the stomach is stretched a lot – for instance after a large meal – the sphincter at the entrance to the stomach might temporarily loosen. Gas or stomach contents might leak up into the food pipe as a result. The sphincter may also sometimes open for no apparent reason, and you might have to belch.
The digestive fluid in the stomach contents irritates the lining of the food pipe, and that is felt as heartburn. If stomach juices stay on the lining of the food pipe for some time, the food pipe might become inflamed. This can be painful.

Symptoms

In some people, stomach contents regularly leak into their food pipe, or a relatively large amount leaks out. This problem is diagnosed as GERD if the reflux causes frequent or severe heartburn or regurgitation that affects their quality of life, or if the food pipe has become inflamed.

Heartburn is felt as a burning pain that spreads from the upper stomach, or from the area behind the breastbone, up into the throat. As well as regurgitation and heartburn, GERD can also be associated with problems swallowing. Other possible symptoms include burning in your throat, a bad taste in your mouth, and stomach noises. People who have GERD often feel very full. They sometimes also feel nauseous and like they need to vomit.

If people have reflux symptoms it does not necessarily mean that their food pipe is inflamed. In up to two out of three people with reflux symptoms, the membranes lining their food pipe are normal.

GERD can cause symptoms that are at first not linked to the disease. For example, the stomach juice that leaks out can get into the windpipe and cause a cough, or it can attack tooth enamel. Other non-typical GERD symptoms include a chronic cough, chest pain, asthma, laryngitis and tooth erosion.

Causes and risk factors

In GERD, the sphincter muscle between the food pipe and stomach does not close properly. It is not always clear why. In some people it is caused by a hiatal hernia. This is where a part of the stomach protrudes up through the diaphragm into the chest. If this happens, the diaphragm can no longer offer enough support to the sphincter between the food pipe and the stomach.

There is some debate about whether being overweight, smoking and drinking alcohol can affect the sphincter at the end of the food pipe or increase the risk of GERD in some other way. Many people with GERD find that stress triggers their symptoms, or makes them worse. Certain postures, such as leaning forward or lying down, or eating particular types of food may also make the problem worse.

Reflux might be caused by problems with the food pipe too. For instance, the food pipe might be too slow at sending rising stomach juices back down into the stomach again, or it might react very sensitively. The symptoms can also be made worse by medications such as “the pill” and certain drugs against high blood pressure.

Outlook

GERD is usually a chronic condition and is typically characterized by recurrent attacks. In other words, someone might not have any symptoms for a while, and then they will have a phase where they have more severe symptoms, followed by another symptom-free phase, and so on.

Effects

A lot of people who have reflux worry about the possible health consequences. But the disease does not usually progress. Sometimes reflux can lead to changes in the mucous membranes lining the lower end of the food pipe. This is then referred to as “Barrett’s esophagus”. It is estimated that 5 out of 100 people who have reflux will develop this condition after some time.

Past research led to the concern that Barrett’s esophagus could increase the risk of esophageal cancer (cancer of the food pipe). However, according to a Danish study published in 2011, this risk is much smaller than previously thought. The known statistics are summarized in the following table. The numbers reflect how many people out of 1,000 are expected to develop esophageal cancer within the next ten years.

Another possible complication is esophageal narrowing, which is where the food pipe becomes narrower. This happens if an inflammation causes damage to the food pipe, and scar tissue forms when it heals. The scar tissue can make the entrance to the food pipe narrower and sometimes make it noticeably harder to swallow.

Diagnosis

GERD can usually be diagnosed based on typical symptoms. It is therefore important to describe your symptoms to your doctor in as much detail as possible, and tell him or her when and how often they occur.

If it is thought that someone might have GERD, doctors sometimes suggest that they have a “trial treatment” for GERD to see if they respond. In what is known as a “PPI test”, they take proton pump inhibitors (PPIs) for about two weeks. PPIs are drugs that reduce the production of acidic stomach juices. If the medication relieves the symptoms, then it is very likely that GERD is causing them.

Treatment

People with severe heartburn or GERD can often relieve their symptoms by changing some lifestyle habits. For instance, they might try to avoid certain types of food, or drink less alcohol. This is not always easy to do, but it can be worth it. There are also medications that can relieve the symptoms. If this does not provide enough relief, surgery might be considered.

Everyday life

GERD can be very distressing, affecting your general wellbeing and everyday life. Some people do not participate in social activities anymore and call in sick a lot. Others feel helpless because they cannot gain control over their symptoms. GERD can also affect your sleep and prevent you from enjoying food and drinks as much as you used to.

Although treatment is not always pleasant and might take some time to work, many people say that they feel better afterwards and that their GERD is no longer such a problem.

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